Download pdf - Celebrate life issue25

Transcript
Page 1: Celebrate life issue25

A publication of

elebrateFor Home TPN and Tube Feeding Patients

Life

September 2011 | Issue 25

H E A L T HNutritionalThe Importance of

CancerwHeN coPINg wITH

Issue Focus:

Page 2: Celebrate life issue25

7 Eating Healthy to Help Prevent Cancer Healthy food choices are a key to the prevention of many diseases, including cancer. A plant-

based diet is a great place to start to benefit from the disease-fighting abilities of diet.

11 Nutrition and Cancer Care: Resource Organizations

12 The Effects of Cancer Therapy on Nutritional Well-Being Cancer treatment can affect nutritional health, while nutritional health can impact a cancer

patient’s recovery. Learn how to anticipate, understand and alleviate nutrition problems as they relate to cancer therapy.

18 Home Care Therapies for Cancer Patients Cancer rates continue to rise in the U.S., but at the same time, treatment options have grown

by leaps and bounds. Learn about what treatment options are available to cancer patients in the comfort of their homes.

20 My Great Adventure Sometimes nutrition support is short-term and uneventful — and sometimes it is anything

but! With a positive attitude and a sense of humor, Michelle Barford, a Coram nutrition support patient, shares her dramatic story.

25 Tube Feeding: A Smart Weapon Against Cancer-Related Malnutrition Studies have shown that cancer patients experience a good quality of life when they are

able to maintain their nutritional well-being. One way to battle cancer-related malnutrition — and one that can be used in the home — is enteral nutrition (EN), or tube feeding.

29 Advocacy Corner: In Case of a Drop in Cabin Pressure, Put Your Mask On First — A Survival Guide for the Caregiver of a Cancer PatientIn the unsettling atmosphere of cancer, the caregiver is a patient’s lifeline. But to be an effective supporter and advocate, a caregiver must take precautions to stay strong. Read about how to take care of yourself as you care for your loved one.

4 Quality of Life and Nutrition Support for the cancer Patient For most people, the main thing that determines quality of life is our ability to enjoy everything life has to

offer with no major health symptoms. Learn about how nutrition support can help improve quality of life for cancer patients.

September 2011 | Issue 25

Celebrate Life The Quarterly Magazine for Home TPN and Tube Feeding Patients

Celebrate Life StaffCarlota Bentley, Managing EditorKaren Hamilton, Clinical EditorLaura Persons, Senior Editor Nancy Geiger Wooten, Senior Designer

Contributing WritersElaine Arthur, RD Michelle Barford, Consumer Tiffany Fancher, PharmD Linda Gravenstein, Consumer AdvocateKaren Hamilton, MS, RD, LD, CNSCCarol Ireton-Jones, PhD, RD, LD, CNSDRoaxana Tamijani, MS, RD, LDCorrie Trottier, MS, RD, LD /NPankaj Vashi, MD

Celebrate Life is published quarterly and provided as a free service to parenteral and enteral consumers. Opinions expressed by contributing authors and sources are not necessarily those of the publisher. Information contained in this magazine is for educational purposes only and is not intended as a substitute for medical advice.

Do not use this information to diagnose or treat a health problem or disease without consulting a qualified physician. Please consult your physician before starting any course of treatment or supplementation, particularly if you are currently under medical care. Never disregard medical advice or delay in seeking it because of something you have read in this publication.

© 2011 Coram Specialty Infusion Services. All rights reserved. No part of this publication may be distributed, reprinted or photocopied without prior written permission of copyright owner. All service marks, trademarks and trade names presented or referred to in this magazine are the property of their respective owners.

We welcome your comments, stories and suggestions. Please send all correspondence to:

Coram Specialty Infusion ServicesCelebrate Life555 17th Street, Suite 1500Denver, CO 80202

Contents

COR09007-0911

Page 3: Celebrate life issue25

3

Celebrate Life is a magazine dedicated to providing home nutrition care patients with very practical information and useful tips for managing their condition. It is a great honor to be guest editor of this issue, which focuses on cancer nutrition and includes articles on a variety of related topics.

As a gastroenterologist and a medical director of the nutrition and metabolic support team at Cancer Treatment Centers of America (CTCA), I have always had a challenging job of managing severe cancer-associated malnutrition. Over the past two decades, home healthcare services have made big strides in helping my patients with their nutritional needs. With great evidence-based studies, we have shown that aggressive nutritional therapies using TPN and tube feeding can be delivered very efficiently and safely to cancer patients in the comfort of their own homes.

I have dedicated the last 17 years to the nutritional needs of patients with advanced cancer. There are still skeptics who are reluctant to consider home nutrition therapy in patients with cancer; however, these numbers are dwindling rapidly. It gives me tremendous professional satisfaction to see the impact of home nutritional therapy on the quality of life of my patients. Therefore, I have included an article in this issue discussing this matter in detail.

In another article, Carol Ireton-Jones and Roaxana Tamijani, two well-reputed dietitians, very eloquently discuss the role of healthy eating in preventing cancer. Lifestyle changes including exercise, weight reduction, abstaining from tobacco/alcohol, and eating healthy are important not only for healthy individuals, but also for patients who are under active treatment for cancer.

Unfortunately, achieving nutritional well-being can be challenging for patients who are experiencing severe side effects from different modalities of cancer treatments. To address this, Karen Hamilton has written a detailed article that can help you better understand and manage these challenges.

Pharmacists play a key role in helping our cancer patients at home. Tiffany Fancher’s article talks about therapies other than TPN and tube feeding that can be provided at home to aid our cancer patients.

The role of a caregiver (a family member or a friend) is a vital part of the success of home nutritional care. An article by Linda Gravenstein — a TPN patient advocate — will help you better understand this role.

For our tube-feeding patients, Elaine Arthur and Corrie Trottier have provided an in-depth commentary on how to successfully manage the different kinds of feeding tubes and specialized enteral formulas.

Nutrition in cancer can be very complex. I am proud to be a contributor to this issue, which addresses the most important challenges for patients today. Enjoy this issue, and as always, we appreciate your feedback.

Dr. Pankaj Vashi, MDLead National Medical DirectorNational Director — Gastroenterology & Nutrition Metabolic SupportCancer Treatment Centers of America at Midwestern Regional Medical Center

A Note from Our Guest Editor

Page 4: Celebrate life issue25

4 | Celebrate Life | October 2011, Issue 25

By Dr. Pankaj Vashi, MD

Quality of Lifeand Nutrition Support

for the Cancer Patient

Page 5: Celebrate life issue25

5

The definition of quality of life (QOL) is different for everyone. But for most people, the main factor that determines QOL is our ability to enjoy everything life has to offer with no major health symptoms. For cancer patients, one factor that can cause health symptoms and have a serious impact on QOL is poor nutrition. For these patients, nutrition support can be an effective treatment option.

Poor Nutrition in Cancer PatientsWeight loss, loss of appetite, and fatigue with generalized weakness are seen in more than 60% of patients with advanced cancer. These symptoms of malnutrition are more pronounced with pancreatic, stomach, lung and colon cancers. Malnutrition in cancer patients results from multiple factors. Nausea, vomiting and diarrhea associated with cancer, as well as the effects of cancer treatments, play a major role. Also, cancer cells produce chemicals that can cause loss of appetite, weight loss and wasting. Other factors include infections, surgeries and underlying depression.

Early detection and aggressive intervention of malnutrition in cancer patients have been shown to have a positive impact on overall recovery and QOL. Unfortunately, the effect of malnutrition on QOL is not well recognized. In fact, in spite of very easy-to-use nutritional evaluation tools available to us, many professionals taking care of cancer patients don’t diagnose early malnutrition. It is not unusual for a physician to come across a cancer patient who has lost more than 30% of their usual body weight in a short period of time, whose professional caregivers have not addressed this weight loss.

Nutrition Support Options: Enteral Nutrition and Parenteral NutritionAn alternate means of nutrition support should be considered in all cancer patients when their oral intake of proteins and calories drops below 60% of the recommended intake. Early interventions should focus on control of symptoms (such as pain, nausea, vomiting, diarrhea and poor appetite). Poor symptom control can have a negative effect on overall nutrition and QOL. Once the symptoms are under control, oral supplementation of liquids and powders high in calories and protein should be implemented. If a patient’s digestive tract is intact and functional, nutritional support with enteral nutrition (EN), or tube feeding, is always preferred. EN can be given through several types of feeding tubes: nasogastric, nasojejunal, gastrostomy or jejunostomy. These tubes are differentiated based on where and how they are placed in the digestive tract. All commercially available enteral feeding formulas are designed to deliver adequate amounts of calories, proteins and vitamins.

Unfortunately, a patient’s digestive tract may not work well due to either severe gastrointestinal side effects of the cancer therapy, or conditions such as malabsorption syndrome, or bowel obstruction that cannot be treated surgically. In patients with such digestive problems, parenteral nutrition (PN), or intravenous nutrition, is the only nutrition support option. The role of PN in cancer patients is controversial — studies done over 20 years ago showed a negative impact of PN on overall recovery in home PN patients. This was mainly due to the high incidence of central line infections and metabolic complications. With improved care and better understanding of

Page 6: Celebrate life issue25

6 | Celebrate Life | October 2011, Issue 25

related chemical functions in the body, we have been able to significantly reduce many of the complications associated with home PN (HPN). Recent studies on HPN in cancer patients have shown it to have a positive impact on overall recovery and QOL.

Tools to Measure Quality of LifeQOL assessment is a type of measurement that can be used in addition to other nutritional evaluation tools. It helps health professionals and the patient to measure the impact of home nutritional support on overall well-being, symptom control, and emotional and functional capacity.

There are many easy-to-use and well-validated instruments that measure health-related QOL. Most of these assessment tools address physical, social and psychological elements. Some of these tools are:

•SF-36 Physical and Mental Health Summary Scale: This tool evaluates the physical, social, emotional and mental state of a patient. It is the most generic tool used for healthcare-related QOL evaluation.

•Karnofsky Performance Scale: This is a very simple and easy-to-use tool.

•EORTC (European Organization for Research and Treatment of Cancer) QLQ-C 30 Scale: This scale was developed initially for international clinical trials. It is now used in many U.S. trials.

•HPN–QOL: This tool was designed specifically for HPN patients and introduced last year. It has a 48-item questionnaire that focuses on physical, emotional and symptomatic issues. It is the most recently created tool, but is not widely used in the U.S.

SummaryNutrition support cannot cure a patient’s cancer, but it can enable cancer patients to continue aggressive cancer treatments and improve how well they function on a daily basis. QOL measurement helps us validate the use of nutrition support, which can be an expensive therapy. While many studies have shown improved QOL in HPN and EN patients, there is need for a large prospective study using one of the standardized assessment tools. QOL assessment should be routinely used in HPN and EN patients to help evaluate the impact of such a complex therapy.

Note: Before considering any nutritional interventions, it is important for you to discuss the risks and benefits of nutritional support with your medical and nutrition team. A team approach involving a physician, dietitian, case manager, social worker and your home infusion company is crucial for a smooth transition from hospital to home while receiving nutrition support. t

References:

1. Mackenzie ML, et al. Home parenteral nutrition in advanced cancer: where are we? Appl. Physio. Nut. Met. 2008;33(1):1-11.

2. Baxter JP et al. A review of quality of life of adult patients treated with long-term parenteral nutrition. Clinical Nutrition. 2006;25(4):543-53.

3. Bozzetti et al. Quality of life and length of survival in advanced cancer patients on home parenteral nutrition. Clinical Nutrition. 2002;21(4):269-71.

4. Aaronson NK et al. The European Organization for Research and Treatment of cancer QLQ-C30: A quality of life instrument for use in international clinical trials in oncology. J Natl Cancer Inst. 1993;85(5):365-76.

5. Huisman-de Waal et al. The impact of home parenteral nutrition on daily life — a review. Clinical Nutrition. 2007;26(3):275-88.

6. Soo I et al. Use of parenteral nutrition in patients with advanced cancer. Appl. Physio. Nut. Met. 2008;33(1):102-6.

7. Marin Caro et al. Nutritional intervention and Quality of life in adult oncology patients. Clinical Nutrition. 2007;(3):289-301.

Page 7: Celebrate life issue25

7

Eating Healthy to Help Prevent Cancer:The Role of a Plant-based Diet

By Carol Ireton-Jones, PhD, RD, LD, CNSD and Roaxana Tamijani, MS, RD, LD

Proper nutrition is about fueling your body to enable it to perform

at its highest capacity. Additionally, healthy food choices are a

key to the prevention of many diseases, including cancer. A plant-

based diet is a great place to start to benefit from the disease-

fighting abilities of diet. Of course, good nutrition can’t work in

a vacuum — other factors like exercise, avoiding tobacco and

reducing stress also help to decrease disease risk. In this article, we

offer suggestions for good food choices. If you receive nutrition

support* and are still able to eat foods, review the information

presented here. Work with your registered dietitian to determine

what will fit with your regimen and improve your oral nutrition to

best suit your health needs.

* If you are on enteral nutrition (EN, or tube feeding) or parenteral nutrition (PN, or intravenous nutrition), you may be curious about nutrition for those formulas. When planning EN or PN regimens, your registered dietitian always keeps complete and personalized nutrition top of mind. In fact, tube feeding researchers are on the cutting edge of nutrition science and ensure optimal nutrient profiles for each formula. Similarly, each PN formulation is developed by the clinician to provide the most beneficial calorie, protein, carbohydrate, fat, vitamin and mineral content to meet each individual’s needs.

Page 8: Celebrate life issue25

8 | Celebrate Life | October 2011, Issue 25

A Plant-Based DietAccording to the American Dietetic Association, people following vegetarian diets have a significantly lower risk of cancer and many other chronic diseases. So, what is a plant-based diet and how does that relate to people who like a cheeseburger now and then? A plant-based diet is one that focuses on whole grains, legumes (beans, peas and lentils), whole fruits, nuts and seeds, and vegetables as primary food choices. Non-fat dairy products can be included in this diet to provide additional protein. Lean meat, poultry and fish can be part of a plant-based diet when included in moderation.

Here’s a fun activity to practice thinking this way: write down your family’s 16 favorite foods from the plant groups: fruits, vegetables, nuts, seeds, legumes and whole grains. We recommend that you focus on unprocessed foods. For example, list apples but not sugary applesauce; peanuts but not chocolate-covered peanuts; or boiled potatoes instead of potato chips. How can you incorporate plant foods in your diet? Just use your list! Start with nutrient-rich fruits and vegetables. Try to eat five to nine cups of fruits and vegetables a day (one cup is about the size of your fist). Fruits and vegetables that are in season are the best choices. What is in season where you are? See our website resources at the end of this article. And don’t forget lentils, beans and peas, which can provide a higher amount of protein than other plant foods (see ‘Plant-based Protein’ later in this article).

GrainsGrains are a great source of fiber and many nutrients. Choose multi-grain breads, whole grain rice and cereal, and try some less common grains like bulgur and quinoa. Steel cut oatmeal is great for its crunchy texture. To reach the recommended goal for fiber of about 25 grams/day, the USDA recommends eating at least three servings of whole grains a day.

A Healthy Meal for a Plant-Based Diet:

• Red beans and brown rice

• Tossed green salad topped with walnuts and strawberries, and olive- oil-and-vinegar dressing

• 8-ounce glass of skim milk

A Healthy Meal for a Plant-Based Diet that Includes Animal Protein:

• Baked salmon

• Sautéed spinach

• Melted lean cheese and mushrooms mixed in whole-grain risotto

• Glass of water

• Dessert of one cup of sliced mango, strawberries and blueberries

Page 9: Celebrate life issue25

9

FatsFat in the diet makes meals tasty and filling. By making better choices in the types of fats you consume, you can also improve your health. For instance, always avoid trans fats, and keep saturated fats to a minimum (you can see the fat content of many foods on their ingredient labels). When cooking, many of us now use liquid oil. Good choices are olive, canola and grapeseed oil. Olive oil can be used in salads or to sauté food, while canola oil is best for baking.

Plant-based ProteinPlant-based protein from non-meat sources can provide what you need to maintain nutritional well-being. In fact, there is a strong relationship between consuming well-done meat, red meat, and cured meat and an increased risk of various cancers. Diets that use only or mostly plant-based protein tend to have a lower risk of cancer. Beans and other legumes are good protein sources, and have the added benefit of fiber and many antioxidants that are associated with lowering disease risk. Legumes also do not have the saturated fat and cholesterol that is found in meat, making it “heart-healthy.” Legumes often easily replace meat in recipes to add a healthful punch to a meal. Some fabulous legumes and protein sources include:

•Soy beans — Try edamame, soy veggie burgers and other meat substitutes, tofu, tempeh patties and soy milk/yogurt.

•Beans, peas and lentils — Try these in soups, salads, pasta dishes and burritos.

•Peanuts — Try these in trail mix snacks, peanut butter, baking and sauces.

Nuts and SeedsWalnuts, peanuts, almonds, pecans, pistachios, pumpkin seeds and other nuts and seeds provide essential fatty acids and antioxidants like vitamin E and lutein, which new research concludes contribute to a reduced risk of many diseases such as cancer and heart disease. It only takes one ounce to make a serving of these plant-based meat substitutes. Nuts and seeds are a tasty snack, and are often palate-pleasing when incorporated into recipes. For example, green salads topped with sunflower seeds or walnuts, or slivered almonds sprinkled over sautéed asparagus, are good ways to eat nuts with meals.

SupplementsOne question many people ask is: what supplements should I take to prevent cancer? As mentioned above, a key in cancer prevention is a healthy, plant-based diet. However, if you also want to take a supplement, taking a multivitamin containing 100% of the RDA (recommended daily allowance) of vitamins and minerals is usually considered safe by most practitioners. Make sure your multivitamin contains vitamin D and folate or folic acid. Recently, the Institute of Medicine’s Food and Nutrition Board increased its recommended amounts of vitamin D intake in its proposed new reference values. Check with your doctor or dietitian to determine the vitamin D level that’s right for you and then supplement accordingly. In some cancer treatment protocols, additional vitamin D is not recommended.

A plant-based diet is evidenced to reduce the risk of cancer and other chronic diseases. Using your plant-based food list and the following Online Health Resources, work with your licensed health practitioner to help you gain an edge on proper nutrition and reduce your risk of cancer and other chronic diseases.

Page 10: Celebrate life issue25

10 | Celebrate Life | October 2011, Issue 25

Online Health ResourcesExplore these Internet resources* for cancer and nutrition topics, risk calculators, support, volunteer opportunities, research participation and more.

•The National Cancer Institute (NCI): www.cancer.gov

•The University of Texas MD Anderson Cancer Center: www.mdanderson.org

•The Center for Nutrition Policy and Promotion, U.S. Department of Agriculture: www.choosemyplate.gov

•Mayo Clinic guide to cooking legumes: www.mayoclinic.com/health/legumes/NU00260

•SNAP-Ed Connection’s “Nutrition Through the Seasons” program on buying and fruits and vegetables in season, from the U.S. Department of Agriculture: http://snap.nal.usda.gov/foodstamp/nutrition_seasons.php

• Institute of Medicine Food and Nutrition Board Report on Vitamin D: www.iom.edu/Reports/2010/Dietary-Reference-Intakes-for-Calcium-and-Vitamin-D.aspx t

* Please note that some organizations may charge a fee for access to services. This listing is not an endorsement of these organizations, or information they may disseminate. We strongly suggest you discuss any information you receive from these organizations with a qualified professional before making any changes in your healthcare, insurance coverage or home care provider.

References

1. American Dietetic Association. Position paper on vegetarian diets. Available at: http://www.eatright.org/About/Content.aspx?id=8357. Accessed 8.22.11.

2. American Dietetic Association. Position paper on nutrient supplementation. Available at: http://www.eatright.org/About/Content.aspx?id=8409. Accessed 8.22.11.

3. MD Anderson Cancer Center. Meat, especially if it’s well-done, may increase risk of bladder cancer. Available at: http://www.mdanderson.org/newsroom/news-releases/2010/well-done-meat-may-increase-bladder-cancer-risk.html. Accessed 5.31.11.

4. MD Anderson Cancer Center. Red meat consumption linked to colorectal cancer. Available at: http://www.mdanderson.org/newsroom/news-releases/2008/red-meat-consumption-linked-to-colorectal-cancer.html. Accessed 5.31.11.

5. American Dietitic Association. ADA Evidence Analysis Library. Available at: http://www.adaevidencelibrary.com/. Accessed 5.23.11.

6. Mayo Clinic. Beans and other legumes: types and cooking tips. Available at: http://www.mayoclinic.com/health/legumes/NU00260. Accessed 5.25.11.

7. U.S. Department of Agriculture. SNAP-Ed Connection. Nutrition through the seasons. Available at: http://snap.nal.usda.gov/foodstamp/nutrition_seasons.php. Accessed 5.31.11.

8. Institute of Medicine. Dietary reference intakes for calcium and vitamin D. Available at: http://www.iom.edu/Reports/2010/Dietary-Reference-Intakes-for-Calcium-and-Vitamin-D.aspx. Accessed 6.2.11.

9. National Cancer Institute. Vitamin D and cancer prevention: strengths and limits of the evidence. Available at: http://www.cancer.gov/cancertopics/factsheet/prevention/vitamin-D. Accessed 6.2.11.

Page 11: Celebrate life issue25

11

Nutrition and Cancer Care: Resource Organizations*

American Cancer Society800.227.2345www.cancer.org

American Dietetic Association800.877.1600www.eatright.org

American Institute for Cancer Research 800.843.8114www.aicr.org

American Society of Clinical Oncology888.282.2552www.asco.org

American Society for Parenteral and Enteral Nutrition800.727.4567www.nutritioncare.org

National Cancer Institute800.422.6237www.cancer.gov

National Center for Complementary and Alternative Medicine (NCCAM)888.644.6226 (NCCAM Clearinghouse)www.nccam.nih.gov

Office of Dietary Supplements301.435.2920www.ods.od.nih.gov

Oncology Nursing Society866.257.4667www.ons.org

* Please note that some organizations may charge a fee for access to services. This listing is not an endorsement of these organizations, or information they may disseminate. We strongly suggest you discuss any information you receive from these organizations with a qualified professional before making any changes in your healthcare, insurance coverage or home care provider.

Page 12: Celebrate life issue25

12 | Celebrate Life | October 2011, Issue 25

The Effects of Cancer Therapy on

Nutritional Well-BeingNutritional well-being varies for people starting cancer therapy. Some people start

therapy with no nutrition problems; others start with a poor appetite, weight loss, and

other nutrition-related issues. For the latter, cancer therapies can complicate treatment

for nutritional problems. In turn, a patient’s nutritional health can affect his or her

ability to tolerate cancer treatment. And both cancer therapy and nutritional health

can impact the patient’s expected healing and recovery process.

By Karen Hamilton, MS, RD, LD, CNSC

Page 13: Celebrate life issue25

1313

The cancer treatments used most often include surgery, chemotherapy, radiation and immunotherapy (cancer medications), each of which can cause nutrition problems. But no matter what type of cancer therapy they undergo, individuals who receive aggressive cancer treatment typically need aggressive nutrition management. The key is to identify the need early and provide nutrition support before an individual becomes too debilitated.

If you are receiving cancer therapy, your healthcare team will assess your baseline nutrition status and evaluate the possible impact of your cancer treatment on your nutritional well-being and vice versa. Then your team will work with you to create a nutrition plan that will help improve or maintain your nutritional status as you go through cancer treatment. The following information can help you anticipate and understand nutrition problems as they relate to your cancer therapy.

Surgery About 60% of individuals diagnosed with cancer will have some type of cancer-related surgery.1 People who are poorly nourished and undergo surgery are at higher risk for post-surgical complications. If the surgery is not urgent, nutrition deficiencies should be corrected beforehand to promote recovery and healing. To do this, nutritional problems should be identified and the best treatment applied. This treatment can include oral liquid supplements, a change in diet, or even tube feeding (enteral nutrition) or parenteral (intravenous) nutrition. Medications may be prescribed to enhance appetite, reduce nausea or help make bowel habits normalize.

After a surgical procedure, nutritional well-being is affected by the area of the body operated on

and the amount of healing needed. Nutritional complications are usually most significant with cancers and cancer treatments involving the gastrointestinal (GI) tract, which extends from the mouth to the anus. For example, if part of the bowel is removed to take out a tumor, a patient may have trouble absorbing nutrients for some time (nutrients are absorbed into the body through the bowel). The amount of healing affects nutritional well-being because healing often increases energy needs and nutrient requirements.

Chemotherapy There are more than 100 different chemotherapy agents approved to treat cancer. Unlike surgery and radiation therapy, which focus on one part of the body, chemotherapy is a systemic treatment (the drug goes throughout the body via the bloodstream). As a result, chemotherapy has the potential for more nutritional side effects than these other treatments. The most common nutrition-related side effects of chemotherapy are poor appetite, taste changes, feeling full earlier than usual, nausea, vomiting, sore mouth or throat, diarrhea and constipation. Poor nutritional well-being and weight loss may prevent a patient from regaining both health and acceptable blood counts between chemotherapy cycles. This can affect the patient’s ability to stay on treatment schedules, which is important in achieving a successful outcome.

Changes in diet are usually encouraged to best manage chemotherapy-related symptoms (see Table 1). Liquid supplements that are high in calories and protein may be used to maintain adequate calorie, protein and vitamin intake. Special formulas may be suggested for people with other medical conditions, such as diabetes or renal failure. 2, 3

Page 14: Celebrate life issue25

14 | Celebrate Life | October 2011, Issue 25

It is important to maintain a healthy diet while receiving cancer therapy. Getting appropriate vitamins and nutrients can help your body cope with the stresses of treatment. Also, by maintaining your calorie intake, it can help prevent or reduce weight loss. Here are some diet pointers for adults:

Following a Healthy Diet During Cancer Therapy

symptoms caused by cancer Treatment

Diet changes to consider

Loss of appetite • Plan a daily menu in advance.•Make every bite count—choose foods high in calories and protein.• Pack snacks to keep on hand throughout the day.• Eat five or six small meals per day.

Trouble swallowing • Consider high-calorie, high-protein milkshakes.• Chew food thoroughly.• Choose soft foods.

Nausea and vomiting • Avoid foods that are spicy or very sugary, fatty or greasy.• Eat smaller, more frequent meals.• Avoid foods with strong smells, or have someone cook for you at their home to decrease strong

odors in your home.• Eat slowly.• Drink beverages between meals, not during meals.• Don’t lie down right after a meal.• Rinse your mouth with lemon water after eating.• Try eating your meals when they are at room temperature.• Try distractions like watching TV during meals.

Diarrhea • Avoid spicy, fatty or greasy foods.• Avoid foods high in insoluble fiber, such as raw fruit and vegetables, and coarse whole grains.• Avoid drinks that contain caffeine.• Try lactose-free or lactose-limited milk products.• Eat more foods containing soluble fiber, such as white rice, bananas, oatmeal, mashed potatoes

and applesauce.• Drink plenty of fluids.

Constipation • Eat more foods containing insoluble fiber, such as fresh fruits and vegetables and whole grains.• Drink plenty of fluids.

Dry mouth • Practice good mouth care. Try a swish-and-spit solution of a ½-teaspoon of salt or baking soda with a glass of water five times daily.• Talk to your doctor about artificial saliva.• Avoid oral care products that contain peroxide or alcohol; these ingredients will dry your mouth.• Try sucking on mints or lemon hard candy. Sugarless gum may also be helpful.

Mouth sores • Try soft or pureed food, or a liquid diet.• Avoid citrus or tomato-based foods.• Consider high-calorie, high-protein supplements.

Taste changes • Try sucking on mints or lemon hard candy to keep your mouth tasting fresh.• Use plastic utensils.• Use herbs, seasonings and marinades in your cooking to increase food’s flavor.

Table 1

Page 15: Celebrate life issue25

15

Radiation Therapy Due to damage it can cause to cells in the digestive system, radiation therapy can make it harder to eat, and impair digestion and absorption of nutrients. Most side effects begin around the second or third week of treatment and dissipate two or three weeks after radiation therapy is completed. However, some side effects can occur or continue long-term after treatment has been completed. 4, 5 Radiation side effects depend on the total dose of radiation, the amount and length of time that radiation treatments are received, and on the area treated.

•Radiation to the head and neck: Some of the more common side effects include taste changes, pain or trouble with swallowing, dry mouth, thick saliva, and narrowing of the upper esophagus (food tube). Patients receiving radiation therapy to this region may have preexisting malnutrition because they simply cannot take in enough food due to chewing or swallowing issues.

•Radiation to the chest: Possible side effects include a sore, inflamed esophagus, trouble swallowing, and esophageal reflux (when stomach contents back up into the esophagus).

•Radiation to the pelvis or abdomen: Diarrhea, nausea, vomiting, enteritis (infection of the small intestine), and malabsorption of nutrients are possible side effects.

Nutrition management can help ease radiation side effects. A study of patients with colorectal cancer receiving radiation therapy showed that dietary counseling can improve patients’ nutritional intake, status and quality of life.9

Many patients undergoing radiation therapy can benefit from nutritional supplements between meals. And if patients can’t eat enough to maintain their weight, aggressive nutritional support can be considered, such as tube feeding or parenteral nutrition. Tube feedings are usually well tolerated and are cost-effective. Numerous studies demonstrate the benefit of tube feedings begun at the onset of treatment (specifically treatment to head and neck regions) before significant weight loss has occurred.10 If tube feedings can’t be tolerated, TPN should be considered.

Immunotherapy Immunotherapy medications include mono-clonal antibodies, which are used to slow the growth of cancer cells; interferon, a common cancer drug; Interleukin-2, which is used to treat metastatic (spreading) renal cell cancer; and granulocyte-macrophage colony-stimulating factor, a common therapy used to increase the production of white blood cells. Some of the more common side effects of these types of drugs include fever, fatigue, weight gain, nausea, vomiting and diarrhea, and loss of appetite.

•Each day, try to eat at least seven servings of fruits and vegetables, six servings of grain products, around six or seven ounces of low-fat meat or fish, and three servings of low-fat dairy products.

•Drink plenty of nonalcoholic or non-caffeinated beverages every day — about eight to ten eight-ounce glasses per day.

•Remove excess fats, sugars and salt from your diet. This is also beneficial because these items tend to be low in nutrients.

• If you simply don’t have an appetite, consider eating smaller “snack size” meals more frequently. Grazing, or eating six to eight small meals per day, may prevent you from feeling over-full or losing weight.

15

Page 16: Celebrate life issue25

16 | Celebrate Life | October 2011, Issue 25

Head and Neck Cancers • Parts of the body affected: The mouth, tongue, jaw, brain,

eye and esophagus.

• Side effects of treatments: Reduced ability to speak, chew, swallow, smell and/or taste.

• Treatment considerations: Many individuals with head and neck cancer are poorly nourished at the time of diagnosis. This is partly because prior to surgery, they may undergo chemotherapy or radiation therapy to shrink their tumors. These treatments can cause nutrition problems because they reduce the patients’ ability to eat by causing mouth sores, taste changes and pain. Many of these individuals benefit from feeding tube placement before surgery. This puts them in better shape to recover from surgery and supports them nutritionally afterward, with the goal of eventually taking an oral diet. Medications may also help.*

Gastrointestinal (GI) Cancers • Parts of the body affected: The lower esophagus, stomach,

pancreas, liver, gallbladder, bile duct, and small and large intestine.

• Side effects of treatments: Gastroparesis (paralyzed stomach that can’t easily push food into the small bowel), changes in digestion, poor absorption of nutrients, poorly controlled blood sugar, elevated lipid levels, fluid and electrolyte imbalance, bowel leak at the surgical site, dumping syndrome (too rapid processing of food by the body, preventing absorption), and vitamin and mineral deficiencies.

• Treatment considerations: Surgery for GI cancer may take a tremendous toll on the body, but it can improve overall chances of survival. The use of tube feeding is common in the treatment of GI cancers. In cases where feeding tubes cannot be placed, or intolerance to tube feeding is noted (such as with persistent nausea, vomiting or diarrhea), parenteral nutrition can be provided.

cancer Types with the Most significantImpact on Nutritional Well-being

If ignored, and if severe, these symptoms can cause gradual or drastic weight loss, which may lead to malnutrition. t

References

1. American Cancer Society website. Available at: www.cancer.org. Accessed April 11, 2011.

2. Eldridge B. Chemotherapy and nutrition implications. McCallum PD, Polisena CG, eds.: The Clinical Guide to Oncology Nutrition. Chicago: The American Dietetic Association;2000:61-9.

3. Fishman M, Mrozek-Orlowski M, eds. Cancer Chemotherapy Guidelines and Recommendations for Practice. 2nd ed. Pittsburgh: Oncology Nursing Press;1999.

4. Donaldson SS. Nutritional consequences of radiotherapy. Cancer Res. 1977 Jul;37(7 Pt 2):2407-13.

5. Unsal D, Mentes B, Akmansu M, et al. Evaluation of nutritional status in cancer patients receiving radiotherapy: a prospective study. Am J Clin Oncol. 2006 Apr;29(2):183-8.

6. Chencharick JD, Mossman KL. Nutritional consequences of the radiotherapy of head and neck cancer. Cancer. 1983 Mar 1;51(5):811-5.

7. McQuellon RP, Moose DB, Russell GB, et al.: Supportive use of megestrol acetate (Megace) with head/neck and lung cancer patients receiving radiation therapy. Int J Radiat Oncol Biol Phys. 2002 Apr 1;52(5):1180-5.

8. Polisena CG. Nutrition concerns with the radiation therapy patient. In: McCallum PD, Polisena CG, eds.: The Clinical Guide to Oncology Nutrition. Chicago: The American Dietetic Association; 2000:70-8.

9. Ravasco P, Monteiro-Grillo I, Vidal PM, et al.: Dietary counseling improves patient outcomes: a prospective, randomized, controlled trial in colorectal cancer patients undergoing radiotherapy. J Clin Oncol. 2005 Mar 1;23(7): 1431-8.

10. Tyldesley S, Sheehan F, Munk P, et al.: The use of radiologically placed gastrostomy tubes in head and neck cancer patients receiving radiotherapy. Int J Radiat Oncol Biol Phys. 1996 Dec 1;36(5):1205-9.

* In one study, head and neck cancer patients who received both megestrol acetate to aid in stimulating appetite, and education on diet modifications, were able to maintain their weight and reported a higher quality of life than those who did not receive any diet interventions. 6,7

Page 17: Celebrate life issue25

17

NoV 15, 2011 — 7:00 pm eastern / 4:00 pm Pacific

Social and emotional coping skills for the holiday season.

“Managing Stress During the Holidays” is part of this free, informational teleconference series. The “Small Steps to Big Steps” series is a great way to learn about topics that affect nutrition consumers from the comfort of your own home.

Managing Stress During the Holidays

Informational Teleconference Series

Featured Speakers: Linda gravenstein, Consumer Advocate, Coram

Mary Patnode, MS, ed, LP, TPN Consumer and Vice President, Oley Foundation Board of Trustees

• Toll-free 866.418.5399• Passcode 3036728726 (when prompted)

If you’ve missed a call, don’t worry! You can still listen to it online at WeNourish.com/consumers/events.aspx.

Missed a Call?

Linda Gravenstein Mary Patnode

Page 18: Celebrate life issue25

18 | Celebrate Life | October 2011, Issue 25

Cancer rates continue to rise in the U.S., but at the same time, treatment options have grown by leaps and bounds. Home care is one of those treatment options. A company that offers comprehensive home

care services can provide the equipment and training needed for patients of all ages with all

types of cancers to receive care at home. If you are a cancer patient, home care can allow you

to remain in the comfort of your own home with your family and friends close by. Receiving

care at home not only improves your quality of life, it also reduces your risk of developing

hospital-acquired infections, and reduces costs.

The primary goals of cancer home care are to keep patients comfortable, and to avoid

hospitalization. Experienced, highly trained home care clinicians can work one-on-one

with your oncologists to provide the individualized care needed to meet these goals.

Home care therapy options for cancer patients may include hydration/fluids, nausea and

vomiting medications, pain management therapies, antibiotics, growth factor therapy, and

even chemotherapy.

Home Care Therapies

by Tiffany Fancher, PharmD

for Cancer Patients

18 | Celebrate Life | October 2011, Issue 25

Page 19: Celebrate life issue25

19

Hydration TherapyDehydration occurs when the body does not have enough water and other fluids to carry out its normal function. This can happen when more fluids are lost than are taken in. Dehydration may be classified as mild, moderate or severe. Anyone can become dehydrated, but people with certain symptoms are more likely to do so. These symptoms, which include intense vomiting, diarrhea, fever, and excessive sweating, are common in cancer patients. Intravenous (IV) hydration/fluid can be given to patients in the home to help return the body to its normal function.

Nausea/Vomiting TherapyNausea and vomiting are side effects seen with some cancer medications, such as chemotherapy. If they are severe enough, a patient may become dehydrated and the body will not be able to function normally. The first step in treating nausea and vomiting is to “break” the cycle as quickly as possible. Many medications are used to control nausea and vomiting, and patients may require several medication changes during the course of therapy in order to find the best drug to stop the problem. In the home, this may involve a combination of oral, rectal and/or IV medications to make the individual comfortable. Trained home care clinicians will help to determine if the patient’s nausea and vomiting are being appropriately treated.

Pain Management TherapyCancer and cancer treatments can be very painful, and difficult for patients to tolerate. Pain medications can be given in the home in different forms, routes, and schedules — even around-the-clock — to keep the patient comfortable. Equipment can even be set up to give additional medication if the patient’s pain suddenly increases.

Antibiotic TherapyIn patients receiving chemotherapy or radiation, the cells that fight off infection are often reduced, leaving the body more prone to illness. To make up for the loss of these cells, antibiotics and antifungals can be used to help rid the body of infections, and many of these medications can be administered in the home. The reduced risk of hospital-acquired infections that home care provides is especially important in these patients with already reduced immune function.

Growth Factor TherapyGrowth factor therapy, a treatment that stimulates cell growth, can be given at home to help the body fight off infections and help bring the immune system back up to its normal function. This treatment is typically given 24 hours to 14 days after a patient receives chemotherapy. Under the direction of their physician, patients can be taught by trained nurses to administer growth factor medications.

ChemotherapyIn addition to these treatments, even some chemotherapy can be given in the home. This can be very convenient for a patient, who can cut down on the number of trips made to the hospital to receive cancer treatments. However, the home infusion company must take extreme precautions to ensure that the patient, the patient’s family, and the nursing staff are well-protected and able to give chemotherapy safely.

Note: If you are having any of these treatments, any concerns you have should be discussed openly with your home care clinician or physician. Also, cancer treatments can have many side effects that may be difficult to manage. It is important to have trained clinicians available around-the-clock to help alleviate these difficulties. t

19

References:

The Mayo Clinic. Available at: www.mayoclinic.com/health/dehydration/DS00561. Accessed 8.24.11; Coram Policy and Procedures

Page 20: Celebrate life issue25

20 | Celebrate Life | October 2011, Issue 25

Page 21: Celebrate life issue25

21

Quite simply, the last three years have been an amazing journey that has tested my inner strength as well as the very core of my being. It started on March 2, 2008, a date that, for me, will “live in infamy.” My husband, Mark — my very best friend and loudest cheerleader — took me to the ER after I experienced severe abdominal pain for 36 hours. I remained in the hospital for over three months, undergoing two abdominal surgeries, the last of which caused complications that resulted in the development of two fistulas1

that made their way through to my skin. I also received a diagnosis of carcinoid, a rare form of cancer. I thought this could not be happening to me, but the looks on the faces of my family and friends made me realize it was. I entered hospice,2

had a PICC line3 placed in my arm, and was put on pre-mixed IV nutrition solution (not one that was customized to my needs, as for TPN).4 In my former life, I had been a hospice nurse. Never would I have thought the word “hospice” could be associated with me as a patient.

I don’t remember much of the rest of that year, except for having multiple episodes of sepsis5

and changes in the PICC location. There were times when the pain was constant. The drugs I was taking to control it made things confusing, and the fistulas would not stop leaking. In my most private moments, I thought death wouldn’t be such a bad thing.

But then, during one of my many ER visits, one of the doctors asked me what my “DNR” 6 status

was. Oh my goodness — we had never been asked that before! The doctor was quite upset and said that as a hospice patient, especially with all of my hospital admissions and near-death episodes, I should have been counseled on my end-of-life directives and choices. I remember clearly stating to him that this was NOT the end of my life — that the end would not happen for a long, long time. I expected to be treated and kept alive to fight another day! At that point, it hit me that no matter how bad things seemed, it sure beat the alternative. I was still on the right side of the grass.

Keeping a Sense of HumorThroughout this whole ordeal, I’ve tried to keep a positive attitude. One day, my daughter Caitlin and I went to the grocery store. I had a huge leak with the “girls” — what I called the fistulas. I told Caitlin, “To heck with this! I don’t care if I drip all the way home. I am going to finish shopping! I already have the biggest butt in the store because of all the padding I’m wearing [to absorb the leakage]. If it’s also wet, we’ll just add it to the long list of ‘silly Mom events’ that we relish telling everyone about!”

From then on, the kids and I no longer looked at my illness with sad eyes. Instead, we had races through the grocery store with the motorized carts. Or, we asked where the bathroom was in whatever store we were in, and then went in

My Great Adventure By Michelle Barford

Sometimes nutrition support is short-term and uneventful — and sometimes it is anything but! With a positive attitude and a sense of humor, Michelle Barford, a Coram nutrition support patient, shares her dramatic story.

Page 22: Celebrate life issue25

22 | Celebrate Life | October 2011, Issue 25

and out a dozen times, watching the faces of the clerks as they wondered what could possibly be causing

this many trips to the restroom.

I also decided to name the two lumens7 of the PICC

line. I called them “Jack” and “Ginger,” because Jack Daniels

and ginger ale used to be my favorite drink. I hadn’t had one in a long time, as alcohol generally aggravated the “girls.” This was my way of staying connected to a former indulgence that I could hopefully resume someday.

Symptoms & Treatments ContinueMeanwhile, my oncologist continued his quest for information on carcinoid. I was his second patient with this diagnosis, so he had gotten up to speed on this rare, destructive cancer. He wasn’t convinced that I was terminal because of the cancer, but was concerned because I kept getting septic. My general health was declining due to the huge output from the fistulas. I had continued pain. And CT scans showed sporadic partial obstructions in my intestines.

Despite all of this, I decided to go to upstate New York over Christmas with Mark and the kids. I thought this would be my last visit to see all my brothers and sisters. My doctor was very concerned about allowing me to go out of town, but sent me on my way with IV antibiotics. I survived the

trip, but upon my return, I promptly developed another bout of sepsis. This time, my oncologist said we needed to get it under control, and the only way to do that was through surgery to repair the fistulas and cut out the carcinoid. He found a doctor at MD Anderson Cancer Center who was willing to consult with us. We drove to Houston, Texas, and for the first time in almost a year, I was hopeful.

In March 2009, I underwent three surgeries to remove the carcinoid and repair my remaining intestines. The surgeons removed a lot of tissue: all but 125 mm of small intestine, 20% of the large intestine, and the mid-abdominal muscle where the fistulas were located. In place of the muscle, they used pig tissue to stabilize my abdomen. I would have only that tissue and my skin protecting my internal organs. I also no longer had my belly button. They couldn’t save it because of the fistulas. In addition to all of this, I had a colostomy.8 I had thought I was done with pouches and leakage, but the doctor said the colostomy was needed because of the “short gut” 9 I would likely develop. He assured me that the colostomy could be reversed at any time. He also said it would take about six months for my remaining small intestine to adjust to its new length, at which time the colostomy bag would no longer be needed. To help keep a sense of humor about the colostomy, I decided to name it. And with a name for it, in case I was out in public and had an emergency, I could simply say “so and so needs attention.” So, “Edgar” was born!

1. Fistula: An abnormal passageway between two organs in the body. For example, an opening (wound) in the skin that connects to one or more internal organs.

2. Hospice: Palliative care (includes pain and symptom management, but not other medical care) for individuals who have a life-threatening illness and a life expectancy of less than six months.

3. PICC line: A central venous access device that is placed in a vein in the arm. The catheter (tube) is threaded up the vein into the superior vena cava (a major blood vessel in the chest).

4. TPN (total parenteral nutrition): Nutrition solution that is sent through an IV (intravenous) into the bloodstream. TPN provides nutrition by bypassing the usual digestive route.

5. Sepsis: An infection in the bloodstream. Sepsis can be life-threatening.

6. DNR: Do not resuscitate. This is an order a patient can request when he or she does not want to receive life-saving care during a medical emergency.

7. Lumen: A port of entry where medication and nutrition are hooked up to the central venous catheter.

8. Colostomy: A surgical operation during which part of the colon (large intestine) is diverted to an artificial opening in the abdominal wall. This is done to bypass a damaged part of the colon. After a colostomy, a bag is worn outside of the body to carry waste.

9. Short gut: The reduced ability of the small bowel (intestine) to absorb nutrients. Short gut is caused by bowel damage or significant small bowel removal.

10. Hickman catheter: A central venous catheter that is placed in the chest wall and tunneled under the skin. It has a smaller amount of tubing that exits the body and is more easily concealed than a PICC line. A Hickman catheter is used for long-term therapy.

11. The Oley Foundation: A nonprofit organization that provides information and support to patients receiving nutrition support. oley.org

Glossary

Page 23: Celebrate life issue25

23

In May, I finally returned home. I was no longer on hospice, and was referred to Coram for home TPN management. Five months after I got home, my worst fears were once again realized — I had another fistula. But this time it wasn’t going through my abdominal wall out of my body; it was leaking into my abdominal cavity. The doctors at MD Anderson tried to repair it through non-surgical means, but nothing worked. My surgeon was adamant that I could not have another abdominal surgery. I could not believe my bad luck. Besides the leaking colostomy, I also had an open, draining hole again that required six to eight dressing changes a day. This was a lot to deal with.

A Chance MeetingIn February 2010, while I was at a Special Olympics event for my son, I saw a woman across the gym who looked familiar. When she walked past me I asked, “Do I know you?” When I told her my name, she gasped. She said she had been one of my nurses at the beginning of all of this, and that I was the sickest patient she had ever nursed. Because she’d moved away, she had sometimes wondered what had become of me — she hadn’t thought I would live this long! She told me that while she was caring for me, she had wanted to share with me the name of another surgeon but had been unable to. So she gave me the surgeon’s name, and two weeks later, when I was in the hospital again with a severe infection, I asked my oncologist to consult with that surgeon. The next day the surgeon came in and examined me. He said he thought he could help me, and I was scheduled for surgery the next day! During the operation, he couldn’t find where the fistula actually was, but he applied plasma gel (a type of surgical glue) to the intestine, and closed me up. We were all so excited! But two months later, the abscess reappeared. I went back to see the surgeon, and he said that I was too high-risk to try surgery again and he had done all he could.

I asked what he would do if he did operate again, and he described a slightly different procedure. He ended the conversation restating that unless I was in a life-threatening situation, he would not re-operate.

Three weeks later, I had an episode of sepsis that landed me back in this surgeon’s office. At that point, he said he would do the surgery! I was scheduled for the following week, and when I woke up after the procedure, the surgeon came in with a big grin on his face. He explained that he had gone hunting for the fistula this time and found an errant suture stuck in the intestine. He had cut it out, applied the plasma gel and started to close me up but thought, where was the cavity where all the drainage collected? He had then made a longer incision, lifted a flap, and there it was — a collection of gunk the size of a small pancake. He had cleaned it all out and closed me up. He said I shouldn’t have any more problems because he had fixed it all this time. After he left, I started to cry. I told my husband that angels were watching over me and brought that nurse to me back in February. Without her I would never have gotten this surgeon’s name and had this opportunity for healing. What a blessing.

In November 2010, I had not had a septic infection for 6 months and my doctor said it was okay for me to have a Hickman catheter10 placed. I was so excited! No more arm tangles and dangling lines — I could hide the central line under my clothes. Things were looking up.

My Life NowIn the spring of 2011, everything was going so well that my husband and I decided I could do a “tag-a-long” on his business trip to Australia, Singapore and

Glossary

Page 24: Celebrate life issue25

24 | Celebrate Life | October 2011, Issue 25

Hong Kong. I contacted customs in the various countries to find out if there were any restrictions or policies regarding bringing in all the medical supplies and oral medications I would need. Australia proved to be the most troublesome country. I needed permits for the heparin and I had to have doctors’ orders, copies of all of the original prescriptions, and stated reasons for everything I was taking both orally and intravenously. This involved three doctors, two pharmacies and Coram.

A week before we were set to leave, the airline informed me that I couldn’t take my TPN on the plane as checked baggage. It all had to go on as carry-on luggage. I called the airline and was told that this was not going to be possible. After I hung up the phone, I started yelling in frustration to no one in particular — how could this be happening? I had planned this meticulously for four months! My registered dietitian at Coram called and listened to my ranting, and then calmly said she would contact some people and get this straightened out. Then I was called by my new best friend, Linda Gravenstein, a Coram Consumer Advocate and mother of a lifetime TPN consumer. She said she would get me on board all the airplanes with my supplies as checked luggage. Not to worry! And I didn’t (well, maybe a little bit!). Sure enough, Linda emailed

me confirmation from the airline that I would be allowed to check as many bags as I needed — and she said I was to go and have fun! She also told me about the Oley Foundation,11 which I googled, and I decided to contact them when I returned. Off we went to Australia and beyond!

Through It All…My family and friends have been and continue to be fantastic! People I don’t even know have met weekly to pray for me and I firmly believe that because of all these prayers, I have lived to tell this story. I am so grateful for the encouragement I’ve been given and for all the help I continue to receive. My doctors and their staff really care about me and do everything in their power to ensure that I get the care I need. I joke with one of the nurse practitioners who saw me early on. He described me at one time as “appearing chronically ill.” I don’t look that way anymore. In fact, when he saw me after an extended lapse of time, he did a double take! I’ve grown to accept Edgar (but don’t tell him that). And as for “Jack” and “Ginger,” I never did reacquire my taste for Jack Daniels — I’ve moved on to Long Island iced tea! Overall, it could be a lot worse. As I’ve said, it sure beats the alternative. I’m grateful to continue to be on the right side of the grass. t

Michelle enjoying stand-up

paddling on a Sunday afternoon . Michelle and her husband at the beach in Australia.

Michelle and her husband in front of the Sydney Opera House.

Page 25: Celebrate life issue25

25

Studies have shown that patients diagnosed with cancer experience a good quality of life when they are able to maintain their nutritional well-being.

Against cancer-Related Malnutrition

Tube Feeding:

A Smart WeaponBy Elaine Arthur, RD and Corrie Trottier, MS, RD, LD/N

25

Page 26: Celebrate life issue25

26 | Celebrate Life | October 2011, Issue 25

There is good news, though. Many studies have demonstrated that patients diagnosed with cancer experience a good quality of life when they are able to maintain their nutritional well-being. However, to stay healthy nutritionally, you need to have weapons ready to do battle against cancer-related malnutrition. One such weapon that may work for you, and which can be used in the home, is enteral nutrition (EN), or tube feeding.

Causes of Cancer-Related MalnutritionMalnutrition — when the body doesn’t have the nutrients it needs to function properly — can be caused both by cancer and cancer treatments. Cancers that affect the gastrointestinal (GI) tract generally cause the most nutrition problems. But anti-cancer treatments for all types of cancer can make it hard to eat and drink. For instance, about two weeks after radiation therapy, you may have loss of appetite, nausea, dry mouth, and a change in taste perception; it may even become hard to swallow. Chemotherapy can produce side effects such as nausea and vomiting, which can make you lose fluids, and perhaps lead to dehydration. Surgery can affect swallowing, digestion and absorption of food.

Cancer and Nutrition NeedsThe first step in gaining or maintaining nutritional health while treating cancer is to follow a healthy diet. Good nutrition helps you maintain your weight and recover better. It is very important

to take in enough protein and calories from the time you are diagnosed with cancer, through your treatment and recovery. This is key because during cancer treatment, your energy needs are higher than when you’re healthy. Healthy people typically need to take in about 1,800 to 2,300 calories. Protein needs are between 60 and 75 grams per day. For people under cancer treatment, their calorie and protein needs vary, depending on things such as their nutritional status before they were diagnosed, the type of cancer they have, and the method of treatment they are undergoing. For example, cancer patients who are underweight need between 2,300 and 2,600 calories every day. For cancer patients with wounds or who are protein-deficient, between 100 and 150 grams of protein are needed to help with healing and replenishing protein stores.

Being diagnosed with cancer can be overwhelming. If you have cancer, you know that there are many decisions to be made about anti-cancer treatment, and things to consider about the impact the disease and treatments will have on your quality of life.

Table 1: Formula Options for Tube FeedingFormula Type Description

Intact Protein: Milk and/or soy protein-based

Standard formula type; meets the needs of most patients. Higher-calorie formulas can provide nutrition in smaller volumes of formula.

Hydrolyzed Protein: Predigested milk protein

Designed for patients who do not absorb standard formulas well enough. Higher-calorie formulas are available to meet needs in smaller volume.

Disease-Specific: Milk and/or soy protein-based

Designed for patients with diabetes, renal failure and lung disease who have failed or cannot use a standard formula.

Hypoallergenic: Amino acid-based

Designed for patients with food allergies.

Modulars: Fat, carbohydrate or protein additives

Include powder and liquid additives to provide additional calories and protein for patients who cannot meet their needs with formula alone.

Page 27: Celebrate life issue25

27

These nutrition needs apply whether or not you can eat food. Eating can be a battle when you’re not feeling well, but there are ways to make it easier — you’ll find some of these ways in this issue’s article The Effects of Cancer Therapy on Nutritional Well-Being. But if you are unable to get enough nutrition from eating foods, or if you simply can’t take in an oral diet without discomfort, tube feeding may be your next step.

Types of Feeding TubesThree types of feeding tubes are available. Your physician will help determine which type best meets your needs.

•A nasogastric tube (NG tube) can be used for temporary enteral support. This small, flexible tube goes in through the nose and passes down the esophagus into the stomach. The tube is taped to the side of the patient’s face for comfort and to help keep the tube in place. Formula can be infused through an NG tube by any of the methods described in Table 2.

•A gastrostomy tube (G-tube) is a more permanent feeding tube, typically used when tube feeding is needed for more than a month. A G-tube, which feeds into the stomach, is usually placed during surgery. A short section of the tube hangs out of the abdomen and can be taped off to the side when not in use. A low-profile G-tube is one that is used for active patients on long-term enteral therapy. It does not extend beyond the abdomen’s surface and so does not need to be taped in place. Any method of formula delivery or infusion can be used with a G-tube.

•A jejunostomy tube (J-tube) is used for patients who need a feeding tube to be placed into their small intestine. A J-tube may also be placed surgically. A J-tube comes with a pump to deliver the formula.

Tube Feeding at HomeUsing tube feeding at home may seem daunting, but your medical team will help you. The goal of enteral support is to nourish the body, and your medical team will help make tube feeding fit into your life as smoothly as possible. You will be taught all aspects of tube feeding, including how to prepare your formula, how to clean the tube site, and how to flush and take care of the tube. Your medical team will also train you to be safe with your equipment. For instance, you’ll learn how to move an IV pole safely around the house, avoiding tripping hazards such as area rugs. You’ll also learn to store formula properly to avoid freezing or spoilage. For additional information about tube feeding, be sure to

Nasogastric Tube

Gastrostomy Tube

Jejunostomy Tube

Stomach

Small intestine

Jejunum

Esophagus

Large intestine

Different types of feeding tubes and their placement

Page 28: Celebrate life issue25

28 | Celebrate Life | October 2011, Issue 25

visit our Nourish™ Nutrition Support Program’s website at WeNourish.com. The site contains a wealth of information for both patients and caregivers.

Transitioning Back to EatingDuring your cancer treatment or afterward, you may move back from tube feeding to an oral diet. Your medical team will help you with this

transition. They’ll help make sure you can take in enough nutrients and fluids. They may suggest keeping a food diary to help you track your intake. Gradually you will advance to pureed foods, then to soft foods, and finally to solid foods. A registered dietitian can help design a diet that works best for you and help make sure you are eating healthily and gaining the right amount of weight. t

Reference: National Institutes of Health, Medline Plus. Available at: www.nlm.nih.gov/medlineplus/ency/article/001042.htm. Accessed 8.24.11.

Method equipment Needed Description Technology/Knowledge Needed costBolus Formula, syringes Using a syringe, the patient first flushes the feeding tube

with water and then pours each dose of formula through an open catheter-tip syringe. The formula is pushed in over 20 minutes and then the tube needs to be flushed again with water. Meal spacing is every 3-4 hours.

May require some level of dexterity (physical coordination). Mimics meal schedule. Portable.

$

Gravity Formula, syringes, IV pole, gravity bags

Using a syringe, the patient flushes the feeding tube with water, and then fills the gravity bag with a dose of formula and connects it to the feeding tube. When a clamp is opened, the formula infuses by gravity over 40 minutes. After disconnecting, the patient again flushes the tube with water. The bag needs to be rinsed between uses. Meal spacing is every 3-4 hours.

This method requires less dexterity. Has a slower rate of feed without the need for a pump. Mimics a meal schedule.

$$

Pump Formula, syringes, IV pole, enteral pump with a carrying case

Using a syringe, the patient flushes the feeding tube with water, and then connects it to the pump set and fills the pump set with the formula. The pump infuses the formula at a controlled rate for a specified amount of time. Some patients need intermittent doses throughout the day, some do better with a set cycle of therapy for part of the day, and some patients do best with continuous therapy 24 hours/day. The patient does need to flush the tube with water on a schedule to meet their fluid needs and keep the tube from blocking off.

Easy to program, although some math may be needed to program the pump correctly.

$$$

Table 2: Tube Feeding Method Options

Page 29: Celebrate life issue25

29

In Case of a Drop in Cabin Pressure, Put Your Mask On First: A Survival guide for the caregiver of a cancer Patient

A caregiver is a friend or family member who cares for the patient, often helping to administer treatment and always providing emotional support. To be an effective supporter and advocate, a caregiver must take precautions to stay strong. Airlines recognize the importance of caring for the caregiver; if you’ve ever flown, you’ve probably heard the common safety refrain reminding passengers that if the need for oxygen arises, they should always put their own mask on first before helping someone else with theirs. This translates to: If you are a caregiver, you have to take care of yourself first. In the case of a cancer diagnosis, caregivers must be able to keep a healthy reserve of energy, positive attitude, time and money so that both the caregiver and their loved one can survive the rollercoaster of emotions that come with cancer testing and treatment.

Following are some tips for taking care of yourself as you care for your loved one. Every tip I share here comes from personal experience or from other caregivers that have been gracious enough to share their journey.

Get help with housework. If you don’t have time to clean your loved one’s home, don’t be tempted to tell your loved one that it can wait. Imagine being unable to leave your house because of fatigue or nausea and just watching the dust pile up around you — but not having the energy to do anything about it! There is a non-profit organization with over 547 partners that provide cleaning services for cancer patients going through treatment. Cleaning for a Reason requires only a letter from the treating doctor; applying is simple and the services are donated. For more information, visit cleaningforareason.org.

Accept help from friends. Being the caregiver of a cancer patient can be rewarding, empowering and satisfying. At the same time, it can be exhausting, depressing and expensive. You must recognize the toll it takes on you and seek appropriate help. For instance, many caregivers are the main source of income for the patient. Taking time off from work can jeopardize insurance benefits and household income. Accepting help is a must.

By Linda Gravenstein, Consumer Advocate

There are few diagnoses scarier than cancer. The possibility of toxic treatments, surgeries, depression, and unknown outcomes can be terrifying for the patient and family. In this unsettling atmosphere, the caregiver is a patient’s lifeline.

ornerC

Page 30: Celebrate life issue25

30 | Celebrate Life | October 2011, Issue 25

Many of us have friends who are available to drive patients to treatments. They are thrilled to be involved and feel good about giving. I have been personally involved in a recent cancer treatment of a dear friend. Her husband continues to work, and taking lots of time off could be taxing. My husband became my friend’s “Kemosabe,” a term from The Lone Ranger TV show that means “faithful friend.” He had shirts made with this printed on them — and thanks me for the opportunity to be involved.

Take care of your own personal health needs. Don’t put off routine doctor’s appointments. And if you find yourself feeling down or depressed, talk to your doctor about possible treatment options. Or try reaching out and talking to others in a support group — this can be therapeutic. Sometimes, just a distraction can do the trick. Treat yourself to a new book, a funny movie, a long walk, or maybe an evening of silly television; these things can do wonders to help recharge your batteries.

Stay organized. The amount of information and paperwork involved in being a caregiver can be huge. Doctors’ names, addresses, and phone numbers are just the tip of the iceberg. Reports, lab results, scans, and bills require a system that you can

manage easily. Create a system that works for you. Just remember that you will be in control when you take charge of the paperwork; some days it might be the only thing you can control! One way organization can help is if you make a monthly calendar of appointments and share it with friends and family — this gives them a heads-up of opportunities to help.

Look online for more resources. For instance, The American Cancer Society website has some wonderful resources for caregivers. It provides tips, information on support groups, and toll-free numbers. You’ll learn about what to expect if you are caring for someone with cancer, as well as find tips on taking care of yourself. You’ll also find checklists that can help you spot signs of anxiety or depression in yourself or others, and learn about coping methods. To learn more, visit the site at: cancer.org/Treatment/Caregivers.

So take advantage of these tips, but also remember: the journey of a caregiver is much like a road trip. The road can be long and the unexpected curves can blindside you, but the time spent with your loved one can be so rewarding! t

Page 31: Celebrate life issue25

31

Page 32: Celebrate life issue25

Celebrate Life MagazineTo submit stories, comments, and suggestions for Celebrate Life, email:[email protected]

WeNourish.com•General information about

the Nourish Nutrition Support Program

•Educational tutorials, videos and downloadable patient education tools

•Consumer events and teleconferences

•Online archive of Celebrate Life magazine

•Consumer resource links

•Local Coram branch maps and information

877.WeNourish (877.936.6874)

Call to speak to a TPN or tube feeding representative.

Nourish Advocacy LineTo reach a dedicated consumer advocate, call:Toll-free 866.446.6373

Informational Teleconference SeriesTo view a schedule of upcoming teleconference topics and times, visit:WeNourish.com/consumers/events.aspx

555 17th Street, Suite 1500, Denver, CO 80202

© 2011 Coram Specialty Infusion Services • Celebrate LIfe is a publication of Coram

Consumer Contacts

elebrateFor Home TPN and Tube Feeding Patients

Life

facebook.com/coramhctwitter.com/coramhc

Connect with us on:


Recommended